Dimitri Antonio Godur, Columbia University, New York, NY
INTRODUCTION
Does a person have the “right to die?” Is there a moral justification to hasten the death of a terminally ill patient? These questions become increasingly important asmedical advances strive to enhance the quantity and quality of human life. Within a culture of self-determination, some b
elieve that people hold the right to end their lives to avoid the suffering of terminal illness. Opponents of this idea, including those in line with the Judea-Christian view, reference the incongruity of this belief with their faith-based ideals. With an aging population facing America, this bioethical dilemma will remain in the forefront of the medical conversation amongst ethicists, patients, and providers for years to come.
BACKGROUND AND TERMINOLOGY
Multiple terms have historically been used to describe a case in which a terminally ill patient uses a lethal dose of medication or medical intervention to end his/her life. A commonly used term in our current lexicon is physician-assisted suicide (PAS). Proponents of this
terminology believe it accurately reflects the relationship between doctor and patient in that it ties the role of the physician to one that aids the patient in ending his/her life. Physician aid-in-dying (PAD) refers to “a practice in which a physician provides a competent, terminally ill patient with a prescription for a lethal dose of medication, upon the patient’s request, which the patient intends to use to end his or her life”(Starks, 2013). Euthanasia involves the use of lethal medications, administered by a physician, to deliberately end a patient’s life.
VIEW OF PAD/PAS PROPONENTS
Those who consider PAD/PAS an ethical option for terminally ill patients cite the bioethical principles of respect for autonomy, beneficence and justice (McCormick, 20
13) to justify their position. With regard to respect for autonomy, competent patients “should have the right to choose the timing and manner of death” (Starks, 2013). Beneficence is tied to compassion, and compassion dictates that it is not always possible to relieve suffering; therefore, PAD/PAS may be a compassionate response to unbearable suffering. Lastly, justice refers to a form of fairness that requires those who are equal should receive equal treatment. Under this guiding principle, “competent, terminally ill patients have the right to refuse treatment that may prolong their death. For patients who are suffering but who are not dependent on life support…refusing treatment will not suffice to hasten death. Thus, to treat these patients equitably, we should allow assisted death as it is their only option to hasten death” (Starks, 2013).
OPPOSING VIEWS OF PAD/PAS
Opponents of PAD/PAS point to the arbitrary nature of guidelines for justifying use of PAD/PAS, particularly with regards to the principles of beneficence and justice. In line with these concerns is the issue that physicians can make mistakes in their diagnoses or prognoses. Many also argue that PAD/PAS is a slippery slope where abuses could easily occur. This could be particularly problematic with implicit or unconscious bias coming into play regarding minority populations and vulnerable groups such as the elderly, disabled, or poor. There is a fear these patients may be influenced to choose PAD/PAS compared to other populations who would perhaps be offered more expensive or complicated palliative care options. Another cause for concern relates to the principle of autonomy. An individual’s request for PAD/PAS may fluctuate from time to time due to other underlying causes such as depression.
MEDICAL VIEW OF PAD
A study conducted by Cohen et al, 1994 found that half of surveyed physicians believe that PAD/PAS is ethically justifiable in certain cases. However, opponents of PAD/PAS have argued that it runs in direct contradiction to the traditional duty of the physician to preserve life and honor the Hippocratic Oath to do no harm. Professional organizations such as the American College of Physicians (ACP) and the American Medical Association (AMA) have argued against PAD/PAS and do not support their legalization (Snyder, 2012).
It is important to note the distinct difference between euthanasia/PAD/PAS and providing pain relief that may accelerate death. Providing pain medication such as morphine to terminally ill patients with the side effect of hastening death is not euthanasia or PAD/PAS as long as it is deemed necessary to relieve the patient’s pain, and that patient comfort is the primary goal. Health care professionals have an obligation to relieve pain and suffering and promote the dignity and autonomy of patients in their care.
ORTHODOX CHRISTIAN VIEW OF PAD
Many religious traditions, including the Orthodox Christian Church, consider PAD/PAS morally wrong because it diminishes the sanctity of life. Fr. Stanley Harakas addresses the topic in his book Living the Faith: The Praxis of Eastern Orthodox Ethicsby answering that “euthanasia done with the knowledge and consent of the patient constitutes the deliberate taking of human life, and as such is to be condemned”. Paramount to his argument stands the Orthodox notion that premature death destroys the image and likeness of God, and as we are not responsible for our creation, we may not tamper with our demise. Fr. Harakas emphasizes that the Orthodox Church believes that to elevate euthanasia to a right would bring it into direct conflict with the fundamental ethical affirmation that as human beings we are custodians of life which comes from a source other than ourselves. Although the Church suffers together with people in their infirmity, the Church cannot forget her mission to preserve the sacred gift of life. Thus, from the Orthodox Christian perspective, “the only ‘good death’ is the peaceful acceptance of the end of earthly life” (Harakas, 1993).
THINKING FORWARD
There are no final clear-cut answers on PAD/PAS from a bioethical perspective. PAD/PAS continues to be a contentious issue in the medical and religious arena. Balancing respect for patient autonomy against other medical and religious principles reflects challenging ethical arguments. Regardless of one’s view on the polarizing issue, the most important factors involved in assisting with any “good death” and providing quality end-of-life care should include compassion, support, respect, appropriate comfort care and communication by medical providers with both patients and families - qualities paramount to treating patients among all stages of life.
REFERENCES
AMA Council on Ethical and Judicial Affairs. (2017). Code of Medical Ethics of the American Medical Association, Chapter 5: Opinions on Care for Patients at the End of Life. American Medical Association. Retrieved from https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/code-of-medical-ethics-chapter-5.pdf
Caplan A.L. (2014). Terminally Ill Woman Chooses Suicide, May Influence a New Generation. Medscape. Retrieved from http://www.medscape.com/viewarticle/833603
Cohen JS, Fihn SD, Boyko EJ, Jonsen AR, Wood RW. Attitudes toward assisted suicide and euthanasia among physicians in Washington State. New England Journal of Medicine. Jul 14 1994; 331(2): 89-94.
Death with Dignity. (2019). Death With Dignity Around the U.S. Retrieved from https://www.deathwithdignity.org
Harakas S., (1982.) Contemporary Moral Issues Facing the Orthodox Christian. Minneapolis, MN: Light & Life Publication Co.
Harakas S. (1993). Living the Faith: The Praxis of Eastern Orthodox Ethics. Minneapolis, MN:
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Hockenberger S.J. (1992).American Nurses Association position statement on promotion of comfort and relief of pain in dying patients. Plastic Surgical Nursing. 12(1):32, 36.
McCormick T.R. (2013). Principles of Bioethics. Retrieved from https://depts.washington.edu/bioethx/tools/princpl.html
Reddy R., Hahn Chaet D. (2018). AMA Code of Medical Ethics' opinions related to end-of-life care. American Medical Association Journal of Ethics. 20(8):E738-E742.
Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. (2012). American College of Physicians Ethics Manual: sixth edition. Annals of Internal Medicine. 156:73-104.
Starks H., Dudzinski D. & White N. (2013). Physician Aid-in-Dying. Retrieved from https://depts.washington.edu/bioethx/topics/pad.html
Wood J. & McCarthy J. (2017). Majority of Americans Remain Supportive of Euthanasia. Gallup. 12 June 2017. Retrieved from https://news.gallup.com/poll/211928/majority-americans-remain-supportive-euthanasia.aspx
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